Younger ER patients with heart attack symptoms should be asked if they've recently used cocaine, which can cause similar chest pain, the American Heart Association warns doctors. For these patients, honesty can be a matter of life or death: Some heart attack treatments can be deadly to someone using cocaine.
New guidelines published online Monday in the American Heart Association journal Circulation say that emergency room doctors need to be aware that symptoms of a heart attack in younger patients with no heart disease risk factors may be caused by cocaine use.
The drug can cause chest pain, shortness of breath, anxiety, palpitations, dizziness, nausea and heavy sweating — all symptoms of a heart attack.
"Not knowing what you are dealing with and giving the wrong therapies could mean death rather than benefit," said Dr. James Reiffel, professor of clinical medicine at Columbia University Medical Center/New York Presbyterian Hospital.
The number of cocaine-related users visiting ERs rose 47 percent from 1995 to 2002, increasing from 135,711 to 199,198, according to the government's Substance Abuse and Mental Health Services Administration. (That's a tiny percentage of the more than 100 million patient visits to emergency rooms each year.)
"The symptoms that they get with the cocaine are very similar to a heart attack," said Dr. James McCord, who chaired the statement writing committee.
Cocaine can cause a heart attack, but only about 1 percent to 6 percent of patients with cocaine-associated chest pain actually have a heart attack, the statement says. Still, doctors say it's important for anyone with chest pain to get it checked out.
Cocaine increases blood pressure and the heart rate, constricting arteries into the heart, said McCord, cardiology director of the chest pain unit for the Henry Ford Health System in Detroit.
"Your heart rate goes up because your heart needs more oxygen, then it shrinks the arteries to the heart," McCord said.
The statement says that since most cocaine-associated chest pain isn't a heart attack, such patients should be monitored instead of being admitted to the hospital. They would have an electrocardiogram and other tests to rule out a heart attack.
"If you admit everyone to hospital with chest pain, you use valuable resources," said Reiffel.
Two typical heart attack treatments can be dangerous to those using cocaine:
• Clot-busting drugs carry an extra risk of bleeding into the brain in patients whose blood pressure is high due to cocaine use.
• Betablockers that can lower blood pressure without constricting arteries in typical heart attack patients have the opposite effect in cocaine users, raising blood pressure and squeezing cocaine-narrowed arteries.
Reiffel said doctors should explain why it's important to know if a patient is using cocaine. He said that admitting use of an illegal substance is confidential information that won't be reported to law enforcement. "The caregiver is not here to judge."
The statement also recommends that cocaine users who do have a coronary artery blockage get a bare metal stent instead of a drug-coated one since chronic drug users may not reliably take the medication needed to prevent new blockages.
McCord said that the drug counseling available in observation units varies among hospitals, and that more could to improve the counseling cocaine-using patients get.
"I think an ideal scenario would be someone whose job is to talk to them about this — explain the extent of the health problems, give them information about resources to help them quit cocaine," McCord said.